Westminster Village: Narcotic Records Missing - IN
Federal inspectors found Westminster Village Kentuckiana meticulously tracked each dose of oxycodone with acetaminophen in their controlled drug record but completely omitted the same information from the patient's medication chart.
The resident, identified as Resident C, was prescribed 7.5 milligrams of the narcotic painkiller every four hours as needed for pain. The physician's order dated June 20, 2025, authorized the around-the-clock dosing schedule.
Staff administered the medication nearly daily throughout August. On August 2, the resident received five doses at 4:00 a.m., 8:00 a.m., noon, 4:00 p.m. and 8:00 p.m. The following day brought five more doses. August 9 saw another five doses, with times ranging from 2:00 a.m. to 9:15 p.m.
The pattern continued for weeks. August 11 through August 14 each showed five documented doses per day in the controlled drug record. August 17 brought six doses, including medications given at midnight, 4:00 a.m., 8:00 a.m., noon, 4:00 p.m. and 8:00 p.m.
Some days showed lighter usage. August 19 recorded three doses. August 20 and August 21 each showed three doses. But the resident received six doses again on August 22 and August 23.
The final week of August maintained the intensive schedule. August 25 showed five doses. August 26 and August 27 each recorded six doses spanning from midnight to 8:00 p.m.
None of these 89 documented administrations appeared on the resident's medication administration record.
Licensed Practical Nurse 12 explained the dual documentation requirement during a September 4 interview. When staff gives a resident's as-needed pain medication, she said, the medication should be signed out on both the controlled drug record and the medication administration record.
The controlled drug record showed staff followed proper narcotic tracking protocols. Each dose included precise timestamps. August 18 recorded six separate administrations at midnight, 4:00 a.m., 8:00 a.m., noon, 6:00 p.m. and 10:00 p.m.
But the medication administration record remained blank for every single dose.
Federal regulations require nursing homes to maintain medication administration records documenting all medications given to residents. The facility's own policy, titled "Documentation of Medication Administration" and dated April 2007, reinforces this requirement.
The policy states that nurses or certified medication aides "shall document all medications administered to each resident on the resident's medication administration record." It specifies that "administration of medication must be documented immediately after (never before) it is given."
Documentation must include the "signature and title of the person administering the medication," according to the facility policy provided by the Director of Nursing.
The missing documentation creates a gap between what the controlled substance log shows happened and what the resident's medical record reflects. While federal drug enforcement protocols captured every narcotic dose, the resident's individual medical record showed no pain medication administration for the entire month.
Inspectors reviewed the clinical record for Resident C on September 3 at 9:55 a.m. The resident's diagnosis included fibromyalgia, a chronic condition causing widespread muscle pain and tenderness.
The inspection occurred after a complaint triggered the federal review. Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
The documentation failure spans 26 days of August, from August 2 through August 28. During this period, staff gave the resident oxycodone with acetaminophen an average of more than three times per day.
August 28 showed four final doses at midnight, 8:00 a.m., 4:00 p.m. and 8:00 p.m. Like every other dose that month, none appeared on the resident's medication administration record.
The violation affects the medical record's accuracy and completeness for a resident receiving frequent narcotic pain medication for a chronic condition requiring ongoing pain management.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westminster Village Kentuckiana from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
WESTMINSTER VILLAGE KENTUCKIANA in CLARKSVILLE, IN was cited for violations during a health inspection on September 4, 2025.
The resident, identified as Resident C, was prescribed 7.5 milligrams of the narcotic painkiller every four hours as needed for pain.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.